Have you been advised by a physician to reduce your alcohol consumption?

Yes

No

Do you smoke or chew tobacco?

Yes

No

Have you used any illegal narcotics?

Yes

No

Is your health impaired in any way?

Yes

No

Are you taking medication?

Yes

No

Do you have high blood pressure?

Yes

No

Do you have asthma, emphysema or respiratory problems?

Yes

No

Do you have cancer or other tumors?

Yes

No

Do you have diabetes?

Yes

No

Do you have AIDS, HIV?

Yes

No

Are you pregnant?

Yes

No

Have you ever been declined life,health or disability insurance?

Yes

No

Are you a U.S. citizen?

Yes

No

Remarks:

Coverage Information

Annual Gross salary including tips, fees, and commissions

How long have you been employed at your present occupation?

What percentage of your income do you want your disability policy to cover?

50%

60%

65%

70%

How long do you want the elimination period to be (length of time you must be disabled before you start to receive benefits)?

How long do you want the benefit period to be (maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)?

Are you self-employed?

Yes

No

What is your occupation?

Please describe your duties at your current job:

Please explain your reason for purchasing disability insurance:

Do you currently have disability insurance?

Yes

No

If yes, how much?

Questions or Comments

Best Time To Contact You

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Evening

Anytime

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